While New York state presses ahead with a voluntary Medicaid managed-care program, its application for a federal waiver to make the program mandatory plods haltingly through HCFA.
"They keep coming up with little, minuscule things (to ask about)," said New York Health Commissioner Barbara A. DeBuono, M.D. "They keep stringing us along."
DeBuono's frustration with HCFA's notoriously slow and meticulous waiver approval process is shared by other state officials. Twenty months have lapsed since Illinois requested a waiver from federal Medicaid requirements, yet state officials still don't know when HCFA's review will be completed.
Miffed by additional terms and conditions HCFA wanted to impose, Arizona recently withdrew a nearly 2-year-old request for a waiver of federal rules affecting "dually eligible" Medicare and Medicaid beneficiaries.
HCFA, the primary payer for dually eligible beneficiaries, insisted on preserving fee-for-service options for Medicare beneficiaries who don't choose managed care and requiring the state to pay deductibles and coinsurance for beneficiaries who receive covered services outside the managed-care network.
In a letter dated March 22, Mabel Chen, M.D., who until recently headed the Arizona Health Care Cost Containment System, said HCFA's position "undermines the intent of the proposal" and "subverts a managed-care approach."
The AHCCCS is Arizona's Medicaid managed-care program.
"Our view is that HCFA is not committed to Medi-caid reform at all," DeBuono charged in an interview with MODERN HEALTHCARE. She said election-year politics have blocked efforts by New York's Republican-led administration to secure HCFA's blessing. "We don't know what else to conclude," she said.
Although the Illinois and Arizona administrations also are led by Republicans, HCFA contends that legitimate concerns over quality, cost and access-not political favoritism-are delaying some waiver approvals.
"Our record is pretty good on this," said Kathy Buto, an associate administrator for policy at HCFA. She said the agency's office of research and demonstrations has approved 13 statewide waivers under Section 1115 of the Social Security Act and that those approvals have been "basically bipartisan."
New York applied for a Section 1115 waiver on March 17, 1995, as part of Gov. George Pataki's plan for increasing Medicaid enrollment in managed-care plans. On Aug. 4, 1995, state officials submitted a 101-page document responding to HCFA's detailed
questions about the proposed program.
Section 1115 of the Social Security Act allows the federal government to waive certain program requirements and authorize states to operate Medicaid demonstration programs.
Some 655,000 Medicaid eligibles currently are enrolled in managed-care plans in New York. Pataki projects state savings of $6 million under the voluntary program in the fiscal year that began April 1. If the program goes mandatory, the state could save $20 million to $25 million.
DeBuono said the difference in first-year savings achieved on a voluntary basis, compared with potential first-year savings under a mandatory program, is "not that great" when measured against the state's $31 billion budget. It's the savings generated in the later years of a mandatory program that really add up, she said.
New York's Section 1115 waiver proposal is the largest HCFA has seen, "so it's a huge responsibility and very technical," Buto said. HCFA is working on terms and conditions now and soon will begin discussing budget issues with the state, she said.
Meanwhile, a 1991 law that directed counties in New York to enroll Medicaid recipients in managed care expires June 30. The Pataki administration believes it has authority under state Medicaid law to continue the voluntary program.
But state Assembly Democrats contend that enabling legislation is required.
Last month, Assembly health, insurance and social service committee leaders introduced a bill to require counties to enroll Medicaid recipients in managed-care plans and establish certain marketing, enrollment and quality review practices.